Paul of Aegina; one of the most influential surgeons of all time

The habit of compilation established by the later Greek and Roman writers remained a set custom in Eastern and Western Europe even beyond the Renaissance period. During the Byzantine period, the most prominent medical personalities were Oribasius (325–403 AD), Aetius of Amida (502–575 AD), Alexander of Tralles (525–605 AD), and Paul of Aegina (Paulus Aegineta). Among these giants, so little is known of Paul of Aegina that it cannot be ascertained in what century he flourished. Moreau and Le Clerc placed him in the fourth century and Vander Linden and Conringius in the fifth; but Albertus Fabricius, Hutcheson, Sprengel, and most of the late writers of the ancient medical history of medicine placed him in the seventh century (625–690 AD). Paul was born on the island of Aegina and practiced medicine in Alexandria. He wrote a medical encyclopedia Epitome of Medicine in seven books. In the introduction, Paul explained why he wrote his condensed encyclopedia of medicine. While it would be extremely difficult, not to say impossible, to retain in the memory the general principles of the healing art, and all the particular means advised by the ancients, I have made this abridgement of what there is in the best of these writings. I have collected the cream of whatever others have said concerning the means of preserving health.

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He also said that he wrote because physicians of his time simply would not read prolix ancient writers—and Galen or Oribasius were nothing if not prolix. His Epitome of Medicine His monumental work (Epitomoe Medicoe Libri Septem) was first printed in Greek by the Aldine Press in Venice in 1528. A copy of this original book is preserved in Special Collections at the Charles E. Young Research Library of UCLA. There are only a few Latin translations that have reached us. Of these translations, the one printed in 1551 was Jacobus Gouplyus’s reworking of the Guinterius translation. The Latin translation printed in 1567 was originally issued in Lyons in 1551, with commentary by Gouplyus, who was the editor of the volume. A copy of each translation is preserved in History and Special Collections Division at the Louise M. Darling Biomedical Library of UCLA. An excellent translation into English by Francis Adams of Banchory was published by the Sydenham Society of London between 1844 and 1847. Each chapter of the text was followed by a brilliant commentary by Adams and by the most important opinions of the Greek, Roman, and Arabian writers on all the medical issues treated by Paul of Aegina. The Epitome was also printed in 1855 with a French translation by René Briau.

In the first book one can find everything that relates to hygiene and to the preservation from, and correction of, distempers peculiar to various ages, seasons, temperaments, and so forth. In the second book is explained the whole doctrine of fevers, an account of certain matters relating to them being premised (such as excrementitious discharges, critical days, and other appearances), and concluding with symptoms that are the concomitants of fever. The third book relates to topical affections, from the crown of the head to the nails of the feet. The fourth book treats those complaints that are external and exposed to view and that are not limited to one part of the body but affect various parts. The fifth book is concerned mainly with toxicology and treatment of the wounds and bites of venomous animals; it also addresses the distemper called hydrophobia, persons bitten by mad dogs, and persons bitten by men. Afterward it describes the problems associated with deleterious substances and the preservatives from them. In the sixth book is contained everything relating to surgery, both what relates to the fleshy parts and to the bones. The seventh book is devoted to pharmacology: an account on the properties of all medicines, first of the simple and then of the compounds. The most noteworthy of these books is the sixth book, which is considered to be the best part of his writings (Fig. 3). Paul was particularly interested in surgery. An examination of his Epitome demonstrates that his sixth book on surgery brought valuable contributions to the history of surgery toward the end of the Eastern Empire.

Paul of Aegina was the quintessential student of the best medical authorities, especially Hippocrates and Galen in, respectively, Greek and Roman medicine; yet he also displayed a peculiar genius with original achievements in the field of surgery. Paul was also the originator of more important surgical procedures than his predecessors, either Oribasius or Aetius. A wide variety of surgical procedures that played a significant role in the history of surgery are presented here. Paul, as a competent surgeon, furnished prior knowledge regarding vascular surgery. He wrote chapters on “Angiology or section of temporal vessels,” “Arteriotomy,” “On hemorrhage from veins and arteries,” “On aneurysm,” “On the excision of varices,” “On venesection.”

His account on varicose veins all over the body is noteworthy. In the chapter “On the excision of varices” he wrote: “The varix is a dilatation of a vein occurring sometimes in the temples, sometimes in the hypogastric region below the navel, sometimes in the testicles, but more especially in legs.” He depicted his ablative surgical technique for varicose veins in the leg as follows. “[H]aving washed the man, and applied a ligature round the upper part of the thigh, we are to direct him to walk about, and when the vein becomes distended we are to mark its situation with writing ink, to the extent of three fingers’ breadth or a little more, and having placed the man in a reclining posture with his leg extended, we apply another ligature above the knee; and where the vein is distended we make an incision upon the mark with a scalpel, but not to a greater depth than the thickness of the skin, lest we divide the vein; and having separated the lips of the wound with hooks, and dissected away the membranes with crooked specilla, like those used in the operation of hydrocele, and laid bare the vein, and freed it all around, we loose the ligatures from the thigh, and having raised the vessel with a blind hook, and introduced under it a needle having a double thread we cut the double of it, and opening the vein in the middle with a lancet, evacuate as much blood as may be required. Then having tied the upper part of the vessel with one of the ligatures, and stretched the leg, we evacuate the blood in the limb by compression with the hands. Then having tied the lower part of the vein, we may either cut out the portion intermediate between the ligatures, or suffer it to remain until it drop out of its own accord with the ligatures; then we have to put a dry pledget into the wound, and apply over it and oblong compress soaked in wine and oil, and secure them with a bandage. . . . I am aware that some of the ancients do not use ligatures, but cut out the vessel immediately after it is laid bare, whilst others stretch it from below and tear it out by force. But the mode of operating now described is of all others the safest.”

He was also an ardent believer in cautery during surgery; in this respect he followed the ancients who believed all material things were made up of four elements—air, earth, fire, water—and that fire was the great purifier. As gangrene of the limbs, cancer of the breast, and so on were extremely harmful things and should be cast off, the ancients and their disciples accomplished this by means of cautery. Although Paul emphasized the value of cautery, for cancer of the breast he recommended extirpation and was opposed to cauterization, in contrast to other physicians. In the case of aneurysms, whereas Aetius suggested that only those of the arm should be treated by radical surgery, Paul recommended that this treatment be used for all aneurysms except those of the cervical, axillary, and inguinal regions. Those which form in the armpits, groin, and neck, and those in other parts of the body, which are very large, we must decline operating upon, on account of the largeness of the vessels. But those which occur in the extremities, the limbs, or the head, we operate upon thus.

For headache, chronic defluxions of the eyes, and vertigo Paul said, “We are in the practice of dividing the arteries behind the ears”. Paul of Aegina gave the fullest account of military surgery of antiquity. His commentaries on penetrating wounds and on the modes of extracting various arrows and other weapons from fleshy parts of the human body, including the heart, lungs, and abdominal cavity, demonstrate considerable personal originality and experience not encountered in the previous ancient authors. He was a firm believer in the use of ligature to arrest hemorrhage before extracting an arrow or a weapon that has lodged in any of the large vessels, such as the internal jugular or carotid arteries and the large arteries in the armpits or groins.

In the head and neck region, several otorhinolaryngologic surgical procedures are discussed in great detail. His chapters “On nasal polypus,” “On tongue-tied persons or anchyloglossus,” “On the uva,” and “On tonsillectomy” bear considerable originality. Paul left us the first classical, detailed description of tracheotomy along with the indications for this operation. In the following chapter, there is a brief description of the method for opening the larynx or the trachea. “[B]ending the patient’s head backwards, so as to bring the windpipe better into view, we are to make a transverse incision between two of the rings, so as that it may not be the cartilage, which is divided, but the membrane in between the cartilages. . . . The surgeon will know that he has opened the trachea when the air streams out of the wound with some force, and the voice is lost. As soon as the danger of suffocation is over, the edges of the wound should be freshened and the skin surfaces brought together with sutures. Only the skin without the cartilage should be sutured.”

Concerning tonsillectomy, he wrote in the following manner. “As indurated glands are called strumae, so the almonds of the ears when inflamed, swelled, and as it were, dried, occasionally difficulty of deglutition and of breathing, are called antiades, from their being placed opposite one another. . . . When the inflammation is considerably abated, we may operate, more especially upon such as are white, contracted, and have a narrow base . . . while one assistant holds his head, and another presses down the tongue to the lower jaw with tongue spatula, we take a hook (tenaculum) and perforate the tonsil with it, and drag it outwards as much as we can without drawing its membranes along with it; and then cut it out by the root with the scalpel suited to that hand, called ancylotomus, for there are two instruments, having opposite curvatures . . . After the operation the patient must gargle with cold water or oxycrate; and if any hemorrhages come on he may use a tepid decoction of brambles, roses, and myrtle-leaves.”

Paul also gave the fullest account we have of ophthalmic surgery of antiquity in his sixth book. Briefly, Paul extracted cataracts and operated for staphyloma, fistula lachrymalis, hypopyon, pterygia, chalazia, trichiasis, symblepharon, lagophthalmos, and ectropion. We quote here his unique description of ectropion and the surgical technique for its correction, with full translation of Chapter 12 from Latin. “Ectropion of the under lid is occasioned by the same causes as lagophthalmos of the upper, only that it does not occur naturally, but arises sometimes from relaxation produced by medicines possessed of this property which have been applied for inflammation; and sometimes the eversion is occasioned by the suture or burning having been improperly performed. Taking a needle, armed with a double thread, perforate the fleshly mass, pushing it through from the left canthus to the right and then by means of the thread fastened to both of its extremities we stretch the skin with the needle and cut down upon it with a scalpel, removing the needle at the same time. Then, if the eyelid resumes its proper shape and is turned inwards, this operation will be sufficient. But if the eversion continues after the removal of the flesh we apply the back of the speculum to the divided eyelid; and on the inside of the eyelid having made two incisions beginning at the two angles of the incision formerly made and terminating in an acute point and meeting together like the Greek letter “^” we remove this substance so that its acute point may be below at the eye and the broad above at what is called the tarsus. Afterwards we unite the separated parts with a needle containing a woolen thread, being satisfied with two sutures. But, if the ectropion be occasioned by the operation of the suture or burning we make a simple incision along the first cicatrix below the hairs of the tarsi and having separated its lips we fill up the wound with pledgets using the same techniques as for lagophthalmos (except fomentation) until the parts which have been stitched unite.”

Several surgical procedures currently practiced in the field of general surgery were discussed explicitly by Paul. For various intra-abdominal infections, such as diseases of the spleen and abscess of the liver, he recommended the use of cautery. In his chapter “On burning over the liver” the surgical technique for draining a hepatic abscess is discussed as follows. “If the pain be attended with weight in those who have abscess in the liver, it is an indication that the fleshy part of the liver is affected; but if the pain be acute the matter is rather in the coats, and we must burn the part thus: Having strongly heated slender, knobbed cauteries, we apply them a little above the loins at the extremity of the liver, making an eschar. But having burnt the whole skin and reached the coat we must evacuate the pus: after the discharge of which, having used lentils and honey, with the applications from honied water, and things of an incarnative nature, we have afterwards recourse to epulotics.”

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He gave the original description of abdominal paracentesis for ascites. “If then the man be standing erect we give orders to the assistants standing behind to press with their hands and push downwards the swelling to the pubes. Then taking a sharp-pointed knife or lancet, if the dropsy is among the intestines, in the perpendicular line of the navel, and about three fingers’ breadth distance from it we divide the hypogastrium as far as the peritoneum. But if the liver be primarily affected we must make our incision on the left side of the navel; or if the spleen, on the right, for we must not make an incision in that part on which the patient is disposed to lie. And having dissected with the point of the instrument the skin that lies over it, we divide the peritoneum a little above the first incision until the instrument comes to an empty space. After this we introduce through the incision of the abdomen and peritoneum a copper tube. . . . [F]or the sake of security, we introduce a twisted tent into the incision of the abdominal parietes alone; and having placed the patient in a recumbent posture and recruited him, we may next day again evacuate through the tube a small quantity of fluid proportionate to his strength; and thus, in like manner, until very little be left, avoiding, by all means, a sudden evacuation. For some ignorant persons having evacuated the vital spirit with the fluid have immediately killed the patient.”

Paul accurately described a radical operation for inguinal hernia. He called scrotal hernias enteroceles and said they are due either to tearing or stretching the peritoneum. Scrotal hernia may be the consequence of injury or violent efforts made while crying. When the scrotum contains only omentum, he called the condition epiplocele, and when it also contains intestine he called it an epiploenterocele. A hernia that does not descend into the scrotum he called a bubonocele. When describing herniotomy, he recommended removal of the testicles, a mutilation perpetuated by the Arabians and that continued to be the vogue with the outcast medieval surgeons until far into the sixteenth century.

The surgical treatment of hemorrhoids, anal condylomas, imperforate anus, and anal fistulas was outlined in considerable detail. Paul employed rectal speculums fitted with expanding screws. No other of the ancient authorities has treated so efficiently a fistula in ano as Paul.

Paul must be credited with unprecedented achievements in the field of genitourinary surgery. He discussed procedures ranging from those used to treat hypospadias to operations for penile cancer, phimosis, hydrocele, and varicocele as well as castration and circumcision. Catheterization of the bladder with subsequent injection of various drugs is described with exactness and originality not found in former work. Thus Paul indicated precisely the curves that the solid catheter must follow in the curvatures of the urethra. “When the urine is suppressed in the bladder, owing to some obstruction, such as a coagulum, or stones, or from any other cause, we have recourse to catheterism for the removal of it. Wherefore, taking a catheter proportionate to the age and sex we prepare the instrument for use. . . . Having then placed the patient on a convenient seat, and used fomentations, if nothing prohibit, we take the catheter and introduce it at first direct down to the base of the penis, then we must draw the privy parts upwards to the umbilicus (for at this place there is a curvature of the passage) and thus push the instrument forwards. When in the perineum it approaches the anus, we must bend the member with the instrument in it down to its natural position, for from the perineum to the bladder the passage is upwards; and we must push the instrument forwards until it reaches the cavity of the bladder.”

The four great medical authors Aetius, Oribasius, Alexander, and Paul agreed on the calculus formation theory in the urinary tract. They supported the hypothesis of the coexistence of two factors required for the manifestation of symptoms: thick material passing through the kidneys and increased temperature. Aetius and other Greek authorities allude frequently to lithotomy, but none described it minutely except Paul of Aegina. In Chapter 60, he described the way in which the lithotome should be introduced, indicating the proper position of the patient during the procedure. “We first have recourse to shaking the patient, in order that the stone may be forced down the neck of the bladder. . . . We take the instrument called a lithotome, and between the anus and the testicles, not, however, in the middle of the perineum, but on one side, towards the left buttock, we make an oblique incision, cutting down direct upon the stone where it protrudes, so that the external incision may be wider, but the internal not larger than just to allow the stone to fall through it. Sometimes, from the pressure of the finger or fingers at the anus, the stone starts out readily at the same time that the incision is made, without requiring extraction; but if it does not start out of itself we must extract it with the forceps called stone-extractor.”

In obstetrics and gynecology, disorders of menstruation, difficult labor, embryotomy, and manual removal of the placenta (also called the secundines) after delivery of the fetus are the main issues discussed by Paul. On difficult labor, he says clearly that “when the fetus is in a preternatural position, we may restore the natural position,” and that, when the position of the fetus is abnormal, “we must first push it upwards from the mouth of the womb, then lay hold of it, and direct it properly to the mouth of the uterus.” However, cephalic version was not expressly described and podalic not clearly described. Because Paul omitted all references to the podalic version, the Arabs who regarded him as Al Qawabilly (The Gynecologist) and the final authority in obstetrics never practiced this procedure; and as a result of Paul’s omission, podalic version disappeared from the obstetrics medical literature. It was finally reintroduced by Roslin and Paré centuries later. Paul also addressed the operations for abscess of the womb, condylomas of the female genitalia, atresia, and partial clitoridectomy. He is recognized for his use of a conical bronze two-bladed vaginal speculum. The preparation of the genital organs is indicated in the following detail. For the operation the woman is placed on a chair, turned backwards, with her limbs flexed against the stomach and the thighs open. The forearm should be placed against the knee and attached to it by a bandage fixed to the nape of the neck. The operator should be seated on the right side of the patient and proceed to her examination with the aid of a speculum, the size of which is proportionate to the age of the patient. If the speculum is larger than the vagina, compresses should be placed on the labia so as not to harm the patient. While the operator holds the speculum, the assistant turns the screw which separates the leaves of the speculum and thus makes possible the enlargement of the vulva.

According to Paul, the most frequent sites of cancer are the uterus and the breast. He regarded operation on the former as useless, in view of the rapidity of recurrence. For cancer of the breast, he recommended extirpation and advised against cauterization, which was recommended by some physicians. Paul generally accepted the theories of Hippocrates, Galen, and Soranus regarding the treatment of fractures and luxations, although he disagreed with various of their points. He discussed procedures ranging from those used to treat nasal fractures, jaw fractures, and cranial bone fractures to operations for a fractured tibia. Soranus differentiated eight types of fracture of the cranium. One was caused by a counter-blow, the very existence of which was denied by Paul. Paul’s description of trephining also differed from that of his predecessors. Interestingly, Paul was the first to describe fracture of the patella and to describe its treatment. None of the ancient authorities have given as full an account of this accident as Paul. Hippocrates and Celsus omitted it altogether, whereas Soranus merely noted the symptoms. Paul’s surgical treatise included several cosmetic procedures. He was the first to describe gynecomastia and its surgical treatment. He was aware that at puberty the breasts of boys could swell to a certain extent but in most cases would involute back to normal. In the chapter “On male breasts resembling the female” he wrote: “[A]s this deformity has the reproach of effeminacy, it is proper to operate upon it. Having, therefore, made a lunated incision below breast, and dissected away the skin, we unite the parts by sutures. If the breast inclines downward, owing perhaps to its magnitude, we make in it two lunated incisions, meeting together at the extremities, so that smaller may be comprehended by the larger, dissecting away the intermediate skin, removing the fat, we use sutures in like manner.”

Surgery appears to have been highly developed by the early Byzantine period. Paul’s sixth book demonstrates that despite scanty anatomic knowledge the technical skill of the surgeons of the period had arrived at such a level that they could successfully perform difficult, delicate operations.

Paul is considered the last representative of Greek science who attained great eminence in his profession. He continued to be looked up to as one of the highest authorities in medicine and surgery during a long succession of ages. Medical authors such as Rhazes (841– 926 AD), Haly Abbas (died 994), Albucasis (936–1013 AD), and Avicenna (980–1036 AD) of the distinguished Arabian period quoted Paul’s opinions on almost every page of their works, and they never failed to recognize him as one the most eminent of their Grecian masters. The sixth book of Paul’s Epitome was the standard work on the subject up to the time of Albucasis and was the textbook of surgery at the medieval University of Paris [34, 46]. The surgical treatise of Albucasis based largely on Paul’s work attained such an important place in surgical literature that it represented the highest authority on the subject during the Renaissance in Western Europe. Sir Clifford Allbutt, commenting on Paul’s influence, said: “His works had a great run from the seventh century down to the Middle Ages”. Another proof of this is the surgical work of Fabricius ab Aquapendente (Girolamo Fabrizi, an Italian anatomist and surgeon, 1537–1619), which is made up almost entirely of Paul’s works.

(Source: “Paul of Aegina: Landmark in Surgical Progress” by Raffi Gurunluoglu et al.)

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Research-Selection for NovoScriptorium: Maximus E. Niles

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